A technique for the treatment of oral-antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy.

A technique for the treatment of oral-antral fistulas resulting from medication-related osteonecrosis of the maxilla: the combined buccal fat pad flap and radical sinusotomy.

Oral Surg Oral Med Oral Pathol Oral Radiol. 2016 Mar 31;

Authors: Melville JC, Tursun R, Shum JW, Young S, Hanna IA, Marx RE

Abstract
OBJECTIVE: Bisphosphonates and monoclonal antibodies directed at osteoclastic function are frequently used to treat postmenopausal and corticosteroid-induced osteoporosis. They are also used in the treatment of certain metastatic malignancies. However, osteonecrosis of the jaw has been reported after intravenous, subcutaneous, or oral use of these agents. More than 12 million Americans and another 20 million worldwide are thought to be taking a bisphosphonate. Exposed bone with oral-antral fistulas has been known to occur increasingly as a specific presentation of what is now termed medication-related osteonecrosis of the jaws (MRONJ) with a specific International Classification of Diseases, 10th revision (ICD-10) code. Oral-antral communications caused by bisphosphonate concomitant with secondary sinusitis represent a unique treatment challenge for the oral and maxillofacial surgeon. The purpose of this article is to demonstrate a simple but effective technique to treat oral-antral communications caused by MRONJ.
STUDY DESIGN: With the review and approval of the University of Miami Internal Review Board, we identified 23 patients who had undergone this surgical procedure.
RESULTS: We report a 100% resolution of osteonecrosis of the jaw (ONJ) and sinusitis with repneumatization.
CONCLUSIONS: The buccal fat pad and radical sinustomy can be used as an effective and predictable technique for the resolution of oral-antral fistulas caused by MRONJ.

PMID: 27307069 [PubMed - as supplied by publisher]

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Per rectal endoscopic myotomy (PREM) for the treatment of adult Hirschsprung's disease - First human case (with video).

Per rectal endoscopic myotomy (PREM) for the treatment of adult Hirschsprung's disease - First human case (with video).

Dig Endosc. 2016 Jun 15;

Authors: Bapaye A, Wagholikar G, Jog S, Kothurkar A, Purandare S, Dubale N, Pujari R, Mahadik M, Vyas V, Bapaye J

Abstract
Hirschsprung's disease (HD) is a congenital disorder characterized by absence of intrinsic ganglion cells in submucosal (SM) and myenteric plexuses of the hindgut; and presents with constipation, intestinal obstruction and / or megacolon. HD commonly involves the rectosigmoid region (short segment HD) although shorter and longer variants of the disease are described. Standard treatment involves pull-through surgery for short segment HD or posterior anorectal myotomy (PARM) in selected ultra-short segment candidates. Third space endoscopy has evolved during the last few years. Peroral endoscopic myotomy (POEM) and peroral pyloromyotomy (G-POEM or POEP) are described for treatment of achalasia cardia and refractory gastroparesis respectively. Using the same philosophy of muscle / sphincter disruption for spastic bowel segments, per-rectal endoscopic myotomy (PREM) could be considered as a treatment option for short segment HD. A 24-years male patient presented with refractory constipation since childhood and habituated to high dose laxative combinations. Diagnosis was confirmed as adult short segment HD by barium enema, colonoscopic deep suction mucosal biopsies and anorectal manometry (HRM). Histopathology confirmed aganglionosis in the distal 15 cm. By implementing principles of third space endoscopy, per-rectal endoscopic myotomy (PREM) 20 cm in length was successfully performed. At twenty-four weeks follow up; patient reports significant relief of constipation and associated symptoms. Sigmoidoscopy, HRM and barium enema confirm improved rectal distensibility and reduced rectal pressures. This case report describes the first human experience of per-rectal endoscopic myotomy (PREM) for successful treatment of adult short segment HD.

PMID: 27307403 [PubMed - as supplied by publisher]

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An Investigation of Feasibility and Safety of Bi-Modal Stimulation for the Treatment of Tinnitus: An Open-Label Pilot Study.

An Investigation of Feasibility and Safety of Bi-Modal Stimulation for the Treatment of Tinnitus: An Open-Label Pilot Study.

Neuromodulation. 2016 Jun 16;

Authors: Hamilton C, D'Arcy S, Pearlmutter BA, Crispino G, Lalor EC, Conlon BJ

Abstract
OBJECTIVES: Tinnitus is the perception of sound in the absence of an external auditory stimulus. It is widely believed that tinnitus, in patients with associated hearing loss, is a neurological phenomenon primarily affecting the central auditory structures. However, there is growing evidence for the involvement of the somatosensory system in this form of tinnitus. For this reason it has been suggested that the condition may be amenable to bi-modal stimulation of the auditory and somatosensory systems. We conducted a pilot study to investigate the feasibility and safety of a device that delivers simultaneous auditory and somatosensory stimulation to treat the symptoms of chronic tinnitus.
METHODS: A cohort of 54 patients used the stimulation device for 10 weeks. Auditory stimulation was delivered via headphones and somatosensory stimulation was delivered via electrical stimulation of the tongue. Patient usage, logged by the device, was used to classify patients as compliant or noncompliant. Safety was assessed by reported adverse events and changes in tinnitus outcome measures. Response to treatment was assessed using tinnitus outcome measures: Minimum Masking Level (MML), Tinnitus Loudness Matching (TLM), and Tinnitus Handicap Inventory (THI).
RESULTS: The device was well tolerated by patients and no adverse events or serious difficulties using the device were reported. Overall, 68% of patients met the defined compliance threshold. Compliant patients (N = 30) demonstrated statistically significant improvements in mean outcome measures after 10 weeks of treatment: THI (-11.7 pts, p < 0.001), TLM (-7.5dB, p < 0.001), and MML (-9.7dB, p < 0.001). The noncompliant group (N = 14) demonstrated no statistical improvements.
CONCLUSION: This study demonstrates the feasibility and safety of a new bi-modal stimulation device and supports the potential efficacy of this new treatment for tinnitus.

PMID: 27310062 [PubMed - as supplied by publisher]

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Tinnitus Screener: Results From the First 100 Participants in an Epidemiology Study

Purpose

In the Noise Outcomes in Servicemembers Epidemiology Study, Veterans recently separated from the military undergo comprehensive assessments to initiate long-term monitoring of their auditory function. We developed the Tinnitus Screener, a four-item algorithmic instrument that determines whether tinnitus is present and, if so, whether it is constant or intermittent, or whether only temporary tinnitus has been experienced. Predictive validity data are presented for the first 100 Noise Outcomes in Servicemembers Epidemiology Study participants.

Method

The Tinnitus Screener was administered to participants by telephone. In lieu of a gold standard for determining tinnitus presence, the predictive validity of the tinnitus category assigned to participants on the basis of the Screener results was assessed when the participants attended audiologic testing.

Results

Of the 100 participants, 67 screened positive for intermittent or constant tinnitus. Three were categorized as “temporary” tinnitus only, and 30 were categorized as “no tinnitus.” Tinnitus categorization was predictively valid with 96 of the 100 participants.

Conclusions

These results provide preliminary evidence that the Screener may be suitable for quickly determining essential parameters of reported tinnitus. We have since revised the instrument to differentiate acute from chronic tinnitus and to identify occasional tinnitus. We are also obtaining measures that will enable assessment of its test-retest reliability.

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Optimal effect-site concentration of remifentanil for preventing cough during removal of the double-lumen endotracheal tube from sevoflurane-remifentanil anesthesia: A prospective clinical trial.

Optimal effect-site concentration of remifentanil for preventing cough during removal of the double-lumen endotracheal tube from sevoflurane-remifentanil anesthesia: A prospective clinical trial.

Medicine (Baltimore). 2016 Jun;95(24):e3878

Authors: Lee SY, Yoo JY, Kim JY, Kim DH, Lee JD, Rho GU, Park H, Park SY

Abstract
Opioids are used as a treatment for coughing. Recent studies have reported an antitussive effect of remifentanil during recovery from general anesthesia by suppressed coughing. The coughing reflex may differ throughout the respiratory tract from the larynx to the bronchi. But the proper dose of remifentanil to prevent cough during double-lumen tube (DLT) extubation is unknown.Twenty-five ASA physical status 1 and 2 patients, 20 to 65 years of age who were undergoing video-assisted thoracoscopic lung surgery requiring 1-lung ventilation were enrolled. The effective effect-site concentration (Ce) of remifentanil for 50% and 95% of patients (EC50 and EC95) for preventing cough was determined using the isotonic regression method with a bootstrapping approach, following the Dixon up-and-down method. Recovery profiles and hemodynamic values after anesthesia were compared between patients with cough and patients without cough.EC50 and EC95 of remifentanil was 1.670 ng/mL [95% confidence interval (95% CI) 1.393-1.806] and 2.275 ng/mL (95% CI 1.950-2.263), respectively. There were no differences in recovery profiles and hemodynamic values after anesthesia between patients with/without cough. No patients suffered respiratory complications during the emergence period.Remifentanil can be a safe and reliable method of cough prevention during emergence from sevoflurane anesthesia after thoracic surgery requiring DLT. EC50 and EC95 of remifentanil that suppresses coughing is 1.670 and 2.275 ng/mL, respectively.

PMID: 27310976 [PubMed - as supplied by publisher]

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Predicting Achievable Fundamental Frequency Ranges in Vocalization Across Species.

Predicting Achievable Fundamental Frequency Ranges in Vocalization Across Species.

PLoS Comput Biol. 2016 Jun;12(6):e1004907

Authors: Titze I, Riede T, Mau T

Abstract
Vocal folds are used as sound sources in various species, but it is unknown how vocal fold morphologies are optimized for different acoustic objectives. Here we identify two main variables affecting range of vocal fold vibration frequency, namely vocal fold elongation and tissue fiber stress. A simple vibrating string model is used to predict fundamental frequency ranges across species of different vocal fold sizes. While average fundamental frequency is predominantly determined by vocal fold length (larynx size), range of fundamental frequency is facilitated by (1) laryngeal muscles that control elongation and by (2) nonlinearity in tissue fiber tension. One adaptation that would increase fundamental frequency range is greater freedom in joint rotation or gliding of two cartilages (thyroid and cricoid), so that vocal fold length change is maximized. Alternatively, tissue layers can develop to bear a disproportionate fiber tension (i.e., a ligament with high density collagen fibers), increasing the fundamental frequency range and thereby vocal versatility. The range of fundamental frequency across species is thus not simply one-dimensional, but can be conceptualized as the dependent variable in a multi-dimensional morphospace. In humans, this could allow for variations that could be clinically important for voice therapy and vocal fold repair. Alternative solutions could also have importance in vocal training for singing and other highly-skilled vocalizations.

PMID: 27309543 [PubMed - as supplied by publisher]

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Motivation in computer-assisted instruction.

Motivation in computer-assisted instruction.

Laryngoscope. 2016 Jun 16;

Authors: Hu A, Shewokis PA, Ting K, Fung K

Abstract
OBJECTIVES/HYPOTHESIS: Computer-aided instruction (CAI) is defined as instruction in which computers play a central role as the means of information delivery and direct interaction with learners. Computer-aided instruction has become mainstream in medical school curricula. For example, a three-dimensional (3D) computer module of the larynx has been created to teach laryngeal anatomy. Although the novelty and educational potential of CAI has garnered much attention, these new technologies have been plagued with low utilization rates. Several experts attribute this problem to lack of motivation in students. Motivation is defined as the desire and action toward goal-oriented behavior. Psychologist Dr. John Keller developed the ARCS theory of motivational learning, which proposed four components: attention (A), relevance (R), concentration (C), and satisfaction (S). Keller believed that motivation is not only an innate characteristic of the pupil; it can also be influenced by external factors, such as the instructional design of the curriculum. Thus, understanding motivation is an important step to designing CAI appropriately. Keller also developed a 36-item validated instrument called the Instructional Materials Motivation Survey (IMMS) to measure motivation. The objective of this study was to study motivation in CAI. Medical students learning anatomy with the 3D computer module will have higher laryngeal anatomy test scores and higher IMMS motivation scores. Higher anatomy test scores will be positively associated with higher IMMS scores.
STUDY DESIGN: Prospective, randomized, controlled trial.
METHODS: After obtaining institutional review board approval, 100 medical students (mean age 25.5 ± 2.5, 49% male) were randomized to either the 3D computer module (n = 49) or written text (n = 51). Information content was identical in both arms. Students were given 30 minutes to study laryngeal anatomy and then completed the laryngeal anatomy test and IMMS. Students were categorized as either junior (year 1 and 2) or senior (year 3 and 4).
RESULTS: There were no significant differences in anatomy scores based on educational modality. There was significant interaction of educational modality by year [F(1,96) = 4.12, P = 0.045, ω(2)  = 0.031]. For the total score, there was a significant effect of year [F(1,96) = 22.28, P < 0.001, ω(2)  = 0.178], with seniors (15.4 ± 2.6) scoring significantly higher than juniors (12.8 ± 3.1). For the motivational score, the total IMMS score had two significant effects. With educational modality [F(1,96) = 5.18, P = 0.025, ω(2)  = 0.041], the 3D group (12.4 ± 2.8) scored significantly higher than the written text group (11.7 ± 3.2). With year [F(1,96) = 25.31, P < 0.001, ω(2)  = 0.198], seniors (13.4 ± 3.0) scored significantly higher than juniors (10.8 ± 2.5). Pearson's correlation showed positive associations (r = 0.22-0.91) between anatomy scores and IMMS motivation scores (P < 0.05).
CONCLUSION: Computer-aided instruction conferred no measurable educational benefit over traditional written text in medical students; however, CAI was associated with higher motivational levels. Computer-aided instruction was found to have a greater positive impact on senior medical students with higher anatomy and motivational scores. Higher anatomy scores were positively associated with higher motivational scores. Computer-aided instruction may be better targeted toward senior students.
LEVEL OF EVIDENCE: N/A. Laryngoscope, 2016.

PMID: 27307270 [PubMed - as supplied by publisher]

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[Diabetes mellitus as a prognostic marker in oropharyngeal and laryngeal squamous cell carcinoma].

[Diabetes mellitus as a prognostic marker in oropharyngeal and laryngeal squamous cell carcinoma].

HNO. 2016 Jun 15;

Authors: Zaoui K, Doll J, Stiebi P, Federspil P, Plinkert PK, Hess J

Abstract
Recent experimental and clinical studies have provided compelling evidence that diabetes mellitus (DM) is an important risk factor in various cancers, and may affect both pathogenesis and prognosis. Additionally, antidiabetic agents such as metformin exhibit an antitumorigenic effect. However, to date there is insufficient knowledge about the role of DM in the pathogenesis and prognosis of head and neck squamous cell carcinoma (HNSCC).In a retrospective monocentric study including 424 patients with SCC of the oropharynx (OPSCC) or larynx (LaSCC), the impact of DM on clinical and histopathologic parameters was investigated. The authors found a rising incidence of DM among LaSCC patients (<10 % until 2005 and 20 % since 2006) and a significant association between DM and clinical and histopathologic features (age, gender, tumor size, and pathologic grading), which depended on the anatomic site. Moreover, a clear trend toward unfavorable progression-free and overall survival of HNSCC patients with DM upon current treatment modalities was evident.The presented data support a relative increase in patients with DM, particularly for LaSCC. This might have a sustained influence on treatment decisions and management, and should be considered in future clinical trials. A better understanding of the cellular and molecular traits of HNSCC in DM could pave the way for innovative therapeutic strategies in terms of personalized medicine.

PMID: 27307061 [PubMed - as supplied by publisher]

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Development of an in vivo model of laryngeal burn injury.

Development of an in vivo model of laryngeal burn injury.

Laryngoscope. 2016 Jun 16;

Authors: Dion GR, Teng S, Bing R, Hiwatashi N, Amin MR, Branski RC

Abstract
OBJECTIVES/HYPOTHESIS: Inhalation injury significantly increases morbidity and mortality in burn patients. Approximately one in five burn patients have acute injury to the larynx, trachea, and/or lungs-and as many as 70% have long-term laryngeal abnormalities. Although inhalation injury to the lung has been studied extensively, no models exist to study these insults to the larynx. As such, we developed an in vivo rabbit model to create precise and reproducible laryngeal burn with resultant tissue damage as a foundation for interventional studies.
METHODS: Following tubeless tracheotomy, a custom temperature-control device was employed to apply heated air (70°C-80°C, 150°C-160°C, or 310°C-320°C) ± smoke derived from unbleached cotton to the larynx, endoscopically, minimizing adjacent tissue damage in six rabbits. Pain, nutrition, and level of activity were monitored. Direct laryngoscopy and histological examination were performed 24 hours following insult.
RESULTS: All animals survived injury with appropriate pain control; oral intake was initiated and all were adequately ventilating via tracheostomy. Burn sequelae were noted under direct visualization 24 hours after injury, and graded levels of edema and tissue damage were observed as a function of temperature. Edema obstructed true vocal fold visualization at increased temperatures. These injury patterns correlated with graded tissue damage on histology.
CONCLUSION: We created an in vivo model of laryngeal burn injury employing a custom burn device resulting in graded tissue injury. This model is critical for investigation of the mechanisms underlying burn injury, and ultimately, the development and evaluation of therapies for this challenging population.
LEVEL OF EVIDENCE: N/A. Laryngoscope, 2016.

PMID: 27305870 [PubMed - as supplied by publisher]

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Therapy of Vestibular Paroxysmia, Superior Oblique Myokymia, and Ocular Neuromyotonia.

Therapy of Vestibular Paroxysmia, Superior Oblique Myokymia, and Ocular Neuromyotonia.

Curr Treat Options Neurol. 2016 Jul;18(7):34

Authors: Strupp M, Dieterich M, Brandt T, Feil K

Abstract
OPINION STATEMENT: Neurovascular compression syndromes are characterized by recurrent attacks of neurological symptoms and clinical signs depending on the cranial nerve affected. It is assumed that pulsatile compression of the nerve is caused mainly by an artery. The result is segmental demyelination of the transition zone or the central part of the cranial nerve, which is covered by oligodendrocytes, and subsequent ephaptic axonal transmission. Compression of the vestibular nerve can cause attacks of spinning or non-spinning vertigo: vestibular paroxysmia. Compression of the trochlear nerve is characterized by attacks of monocular oscillopsia: superior oblique myokymia. Damage to ocular motor nerves due to local radiation or rarely neurovascular compression can also lead to oscillopsia and double vision precipitated by sustained excentric gaze: ocular neuromyotonia. It is important to note that controlled trials have so far not been performed for any of these three syndromes, mainly because of their low prevalence. Therefore, treatment recommendations are based on single cases or small case series and thus have the lowest level of evidence. The sodium channel blockers carbamazepine (50 to 200 mg tid) or oxcarbazepine (100 to 300 mg tid) are evidently effective in most of the patients who have these three syndromes. However, one should always keep in mind the contraindications, side effects, and interactions with other drugs of carbamazepine ( http://ift.tt/1Ou1j6T ) All patients require regular laboratory examinations. Alternatives are other sodium channel blockers such as phenytoin (100 to 300 mg tid), gabapentin (100 to 600 mg tid), or valproic acid (100 to 300 mg tid). Furthermore, there are also few reports on the effects of beta blockers, which may be explained by their reduction of the amplitude of blood pressure. Patients who do not respond to pharmacotherapy require further diagnostics to determine the possibility of other etiologies. Some of these patients benefit from surgical decompression of the affected nerve.

PMID: 27306762 [PubMed]

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